Where Are We On The Science Of Menopause?

FLORA LICHTMAN: This is Science Friday. I’m Flora Lichtman. Menopause is kind of having a moment.

DREW BARRYMORE: Everybody, we are here with the one and only Halle Berry. And we have one big thing in common. We are both in perimenopause.

NEWSCASTER: Actress Naomi Watts was among the first to speak openly about menopause.

OPRAH WINFREY: I had never heard that heart palpitations was a symptom of menopause. I wanted to do this because when I was going through it, there was nothing. There was nobody. I felt literally like I was going to die.

FLORA LICHTMAN: Besides the celebrity testimonials and Oprah special, there have been a bunch of books that make menopause or perimenopause a plotline. All this to say, menopause, at last, has gone mainstream. But it wasn’t until about three decades ago that menopause research really kicked into gear. And since then, we’ve made big progress in understanding this basic biological process that affects half of the population. But there are still many more questions to be answered.

Here to help through the science of menopause are my guests, Dr. Monica Christmas, associate professor of Obstetrics and Gynecology at the University of Chicago and director of the Menopause Program at UChicago Medicine, and Dr. Carrie Karvonen-Gutierrez, associate professor of epidemiology and the director of the Center for Midlife Science at the University of Michigan, based in Ann Arbor. Welcome to you both to Science Friday.

MONICA CHRISTMAS: I’m excited to be here.

CARRIE KARVONEN-GUTIERREZ: Thanks for having us.

FLORA LICHTMAN: Carrie, let’s start with some basics. What is physiologically causing menopause?

CARRIE KARVONEN-GUTIERREZ: Yeah, that’s a really good question. So menopause itself happens because the hormones that control our menstrual cycle in our body, which are mainly estrogen and progesterone, are produced in much smaller amounts in the ovaries as women age. What happens is that these hormones don’t stop all at once, which is why we see the menopause as a transition rather than as an immediate event.

And what we see with menopause and many of the symptoms is due to estrogen dropping because it affects many parts of the body, not just the reproductive system. And so when its levels go down, it can lead to a variety of different symptoms that are hallmark, like hot flashes, night sweats, and so forth. And we define menopause clinically and for research purposes as the point 12 months after a woman has her final menstrual period. And that marks the end of her reproductive years.

FLORA LICHTMAN: So is the menopausal transition the same as perimenopause?

MONICA CHRISTMAS: The perimenopause transition is when you start having those menstrual cycle changes up to the last menstrual period. And perimenopause also includes the menopause transition plus that one year before the menopause actually is defined.

FLORA LICHTMAN: So you don’t know that you’ve completed menopause until like 12 months after you’ve completed it. Does that sound right?

MONICA CHRISTMAS: It’s true. It is retrospective. But it’s important to say that there’s not one menopause syndrome that every single person gets. There are people that get very few symptoms, if any at all, that are short lived. And then there’s people at the other end of the spectrum, too. And I think that’s where things get confusing.

FLORA LICHTMAN: Well, how do you figure out whether what you’re experiencing is normal or not?

MONICA CHRISTMAS: From a clinical perspective, I don’t get to choose what’s really bothersome to people. The hard part about this discussion and what’s most confusing to clinicians as well as the people experiencing the menopause transition is that this time frame also coincides at a point where we are aging. And it’s often difficult to truly disentangle what’s truly due to menopause versus what is due to the chronological aging process.

However, that menopause transition, where our hormone levels are fluctuating– and it’s not often the absence of estrogen, but it’s that fluctuation. Because sometimes before those ovaries kind of conk out, they start malfunctioning a little bit. Sometimes they’re creating more estrogen than is really needed, and then sometimes they’re completing less. And it’s often that fluctuation, especially for things like mood swings or anxiety, that are triggering those type of symptoms. And the good news is it doesn’t last forever.

FLORA LICHTMAN: Carrie?

CARRIE KARVONEN-GUTIERREZ: So one of the studies that has done a tremendous amount of work in understanding and disentangling these two ideas of reproductive aging versus chronological aging is the Study of Women’s Health Across the Nation, or affectionately called SWAN.

That study has been going on for nearly 30 years now, and has followed a cohort of over 3,000 women from their premenopausal life stage into their mid ’70s now. And so we can analyze our data in a way that will help us disentangle which changes or which types of symptoms a woman might be experiencing that are, in fact, due to that menopausal transition versus those that are due to aging as a process overall.

MONICA CHRISTMAS: And it’s also a diverse group of individuals, which is really exciting too. It’s racially and ethnically diverse. So that data is such a meaningful contribution to midlife women’s health and understanding it.

FLORA LICHTMAN: Well, do people of different demographics experience menopause differently? Are there correlations or trends there?

CARRIE KARVONEN-GUTIERREZ: We do have data from SWAN, and we do see that there are notable differences in menopause experiences, particularly between Black and white women. In particular, we find that Black women, on average, tend to reach menopause at a slightly younger age compared to white women. And they have a more symptomatic experience. They report experiencing hot flashes and night sweats with greater prevalence. They have longer durations of those symptoms and often with greater severity.

FLORA LICHTMAN: Why?

MONICA CHRISTMAS: That’s a good question. I don’t know that we can answer that one. But not just for Black women, things are multifactorial. And there are lots of things that play into it. SWAN looked at just a cohort from the United States. But if we look at data that’s international too, depending on where you live, what your sociocultural influences are, what your underlying mental and physical health is all play a role in how you experience the menopause transition.

One of the things that came with SWAN too, I actually used their data for some of this to publish a paper, was that the uptake of treatment was different too. Meaning in our SWAN cohort that more white women were open or receptive to taking hormone therapy, whereas the other racial ethnic groups preferred more complementary or integrative modalities for managing their symptoms as well.

FLORA LICHTMAN: What is the treatment for menopause?

MONICA CHRISTMAS: It depends on what we’re treating. And more recently in the media, almost hormone therapy has become synonymous with menopause. Now I feel like there’s this demand for hormone therapy like it’s the antidote to aging or the cure-all for everything, which it is not, spoiler alert. What does it help? Well, we know that hormone therapy helps minimize hot flashes and night sweats. It’s one of the most effective treatment options for managing those symptoms.

But, again, how we manage things really depends on what the person’s symptomatology is. In that perimenopause time frame, often the first symptom is changes to the menstrual cycle. And they can be varied. Some people they get shorter, they get lighter, they space out, and then they just politely go away. Other people may notice that their menstrual cycles are getting heavier.

Often, the mood swings are the most common during that perimenopause transition too. And so if we think the mood swings are truly just due to these hormonal fluctuations, hormonal birth control can actually help to stabilize hormone levels so that mood is better too. But that’s not a first-line treatment for mood disorders. So they might need a mood stabilizer like an antidepressant.

FLORA LICHTMAN: Carrie, are there long-term risks of hormone therapy?

CARRIE KARVONEN-GUTIERREZ: The early 2000s were hallmarked by the finding from the Women’s Health Initiative, or the WHI, that I think scared a lot of individuals, a lot of women, a lot of clinicians, given that the finding was that the usage of hormone therapy was associated with an increased risk of breast cancer and an increased risk of cardiovascular disease in some women, including blood clots, stroke, and heart attack.

Understandably, those findings led to a lot of concern. We saw in our data from SWAN that there were dramatic changes in usage patterns. And there’s been an ongoing debate continuing in the field about when, for who, and how long hormone therapy should be used.

MONICA CHRISTMAS: So it gets really complicated. But there’s a window of opportunity, I’ll say, or this timing hypothesis that we call it in medicine, when the benefit of hormone therapy seems to outweigh the risks– now, we can never say that there’s zero risk– but in younger individuals, meaning under the age of 60 or within 10 years of the onset of menopause.

However, in individuals over the age of 60 or more than 10 years from the onset of menopause, that risk-benefit profile starts to shift a little bit, where we start to see more risk associated with long-term hormone therapy use. And those risks are actually increase in cognitive decline, increase in cardiovascular risk, stroke, blood clots like pulmonary embolism or deep vein thrombosis, increased in gallbladder disease, and an increased risk in breast cancer, especially with estrogen and progesterone together. So it’s not just an easy answer.

FLORA LICHTMAN: Do different experiences of menopause correlate with or cause different long-term health outcomes?

CARRIE KARVONEN-GUTIERREZ: Yes, we do see that from the data in SWAN. This is, I think, one of the most pressing research questions that we have now about the menopausal transition and understanding what the experience of menopause is and how it relates to one’s long-term health. We certainly know that individuals who go through a very early menopause before age of 40, 42 have earlier incidence of some major healthcare outcomes, including cardiovascular disease and osteoporosis.

But we do need to understand better how those changes in physiologic health outcomes across the board, including brain health, cardiovascular health, metabolic health that do occur during the menopausal transition, whether or not those are persistent and associated with long-term health outcomes for major age-related diseases. And those changes that we might be looking at during the menopause include things like the timing of the menopausal transition, how quickly one goes through the menopausal transition, and how symptomatic their transition is.

FLORA LICHTMAN: OK. I know that we’re learning a ton, more every day, thanks to you two. And at the same time, I also know that medical research has historically sidelined women, ignored women. And I wonder how you think that has affected our knowledge of this process that affects half the population.

MONICA CHRISTMAS: Absolutely, it does impact things. One of the benefits to menopause having its moment right now, as you said, is that it is shedding more light. And hopefully with shedding more light, it sheds more money. Because that’s how we promote–

CARRIE KARVONEN-GUTIERREZ: [LAUGHS]

MONICA CHRISTMAS: –and have more research findings.

CARRIE KARVONEN-GUTIERREZ: Yeah, I want to go back to something that Monica said that I think is really important. It’s not that we have a lack of understanding of menopause. But I think the work to do now is to really turn this time, this menopause as a movement, into action.

And this also leads into policy. There’s now more than a dozen states in the country that have legislation being considered related to menopause, whether it’s increasing training for healthcare providers in menopause science, whether it’s workplace accommodations, or something of the sort.

MONICA CHRISTMAS: I love allowing for workplace accommodations that support women that are going through this time frame that are not penalizing. And I’m in this age group myself. Just because we’re menopausal does not mean that we’re not productive contributors to the fields that we are in. And so I definitely don’t want to get to a point where we have created for a natural condition that happens to 50% of the population that we are overmedicalizing it to and then penalizing women.

I think that when we think about menopause support, it’s both ways. How do we create a medical system? Not just the physician part of it, but that we accommodate coverage for the visit itself as the support, mental health service support, as well as drug support. So that’s my two cents.

FLORA LICHTMAN: Before we go, what is the biggest piece of misinformation you deal with around menopause or perimenopause?

MONICA CHRISTMAS: What always makes the hair stand up on the back of my neck, when I hear, we don’t anything about menopause. There’s no research. That’s absolutely not true. Now, with all things in medicine, we are constantly looking for new, innovative treatments or understanding novel ways to manage things. And that’s just the beauty of science, which both why Carrie and I are in this field, probably, because it’s ever changing. But we build on the heels of all of the research and information that we’ve had that’s come before.

FLORA LICHTMAN: Carrie, do you have a hill?

CARRIE KARVONEN-GUTIERREZ: I do have a hill.

MONICA CHRISTMAS: [LAUGHS]

CARRIE KARVONEN-GUTIERREZ: I think one of the most common myths related to menopause is that it’s always a negative experience.

MONICA CHRISTMAS: Oh, yes.

CARRIE KARVONEN-GUTIERREZ: I think we talk a lot about the symptoms. And it does, it brings challenges. Many people find it to be bothersome in many ways. But I think the reality is that many people often find freedom and new possibilities and improvements in some health conditions as they transition through menopause. It’s freedom from periods and menstrual symptoms.

It is bringing relief, perhaps from certain health conditions like fibroids or PMS or endometriosis. It’s often an opportunity for a health reset. The menopausal transition will often be a time period when women take restock of their health and make positive changes. And we often do see that with the greater focus on relationships, children might be leaving the home, it’s an opportunity for a new chapter.

And with that, it’s sometimes seen as a time of renewal. We actually do see that some mental health metrics tend to improve as one goes beyond the menopausal transition. And so it’s an opportunity for women to really take care of themselves and foster their health in a way that will improve their life and their well-being for the decades to come.

MONICA CHRISTMAS: Carrie, that’s so important. And in many cultures, this is a time frame where women are held to a different level of esteem. You’ve reached this age and this wisdom period that’s really respected. Unfortunately, I think in our country, though, that aging women are often stigmatized in a negative way. And that fuels this more negative conception or connotation of menopause.

So I’m so glad you said that because it’s very true. It’s not always a negative experience. But if we portray it that way, then our minds are very powerful. If we tell people that this is horrible, they believe it. I get lots of patients now in their 30s asking me what they can do to prevent menopause. And I often look and say, die, and I don’t think we want to–

[LAUGHTER]

FLORA LICHTMAN: OK, well, I think that’s the perfect place to leave it. Thank you both so much for being with me today and for this thoughtful conversation.

CARRIE KARVONEN-GUTIERREZ: Thanks for focusing on menopause. I think it’s an important topic and glad to have been here.

MONICA CHRISTMAS: This has been wonderful. I’m honored to have been asked and, thank you.

FLORA LICHTMAN: Dr. Monica Christmas, associate professor of Obstetrics and Gynecology at the University of Chicago and director of the Menopause Program at UChicago Medicine, and Dr. Carrie Karvonen-Gutierrez, associate professor of epidemiology and the director of the Center for Midlife Science at the University of Michigan, based in Ann Arbor.

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